Monday, December 22, 2008

My husband was talking to a non-medical friend at a party the other night, and he referred to internship as being "god-awful." I immediately turned to him and corrected him.

I do not think internship is god-awful.

In fact, I have been fairly happy lately.

Yes, I have been really stressed out. I have cussed out loud while getting gang-paged and dropping the call pager into a cup of coffee. I have been (unintentionally) surly to nurses who have paged me for 2 am constipation. I have had months where I've been very sleep deprived and cranky. My house is filthy. I almost never cook dinner. I've put weight back on because I am often too tired or busy to go to the gym. Sometimes I snap at my husband out of stress and anxiety.

It's also true that I've been to 2 excellent rock concerts and 1 symphony concert since starting residency. I've gone to visit my sister. I've made friends with some of my neighbors, who are awesome people (and closed my garage door for me last night, since I left it open by accident). I've kept up with friends nearby and seen 2 friends who moved cross-country for residency. I've read a few non-medical books and played a lot of Rock Band (II was my birthday present!) Thus far, I've kept up my blog, and my reading of multiple blogs (thank you, Google Reader!). We put up our tiny Christmas tree and some really puny Christmas lights, which somehow makes me really happy. My husband remains incredibly supportive through all of this and still spoils me rotten.

In residency, I've almost finished 6 months at several different hospitals, some inpatient, some outpatient. I've taken some call and learned a ton. I've learned a lot about teaching med students and giving on-the-spot feedback (although I'm definitely still a beginner). I found out I really liked internal medicine as a resident, which surprised me (I really didn't like it as a student). In fact, I liked IM so much, I have concerns about how much I'll like psych when I start in January. I'm studying for Step 3 and it's astonishing how much I've learned, how much I've forgotten, and just how much there is that I've never learned about.

Now obviously, I'm not a general surgery intern, or even a medicine intern. Psych internship is relatively cush compared to what many interns endure. I could imagine that other interns are way less happy. Overall, though, when I look at my current lot in life, I'm pretty satisfied, and look forward to where this is all going. So no, residency is not god-awful.

Saturday, December 20, 2008

There is a post over at Shrink Rap this week regarding an article in the Psychiatric Times, written by a psychiatry resident. The article got posted to several weblogs, and suddenly the author's email address ended up posted in the comments section. Now, you have an article that was written for an audience of psychiatrists, therapists, and other health care professionals. I really doubt that the author intended for this article to get posted to the internet for all the world to read.

The problem is, now this article is out there. The article featured the author's name and school affiliation. While I'm sure she changed some identifying characteristics, there's still a potentially recognizable patient in this article. As someone pointed out to me, if this patient felt the urge to Google his former therapist's name (which is not uncommon--who hasn't Googled themselves? Um, I mean, not me) then he'd find this article very easily. Chances are, this patient may identify himself in this article, especially since the therapist's name is attached. It's unclear from the article whether the patient gave his permission to have his story used in this manner, but given the tone of the article it seems unlikely.

How is this better than an anonymous blog with patient identification removed and characteristics changed?

Yet, some residencies will allow, even encourage their residents to publish in magazines and journals like Psychiatric Times, yet have policies forbidding residents to write blogs or post to message boards. I feel that policies regarding internet writing should be more reasonable and take into account the level of anonymity of the blog. It's one thing to post publicly "I'm a resident at XX school and my name is YY and I worked 95 hours last week and I think this affected my patient outcomes"--which seems to be what residency programs are afraid of, and what lawyers may look for in litigation. It's entirely another to post anonymously, take careful precautions with patient identification, and be deliberately vague.

One argument I could foresee regarding the difference in regulation is that an article in a journal or industry magazine is published with the intent to educate, whereas a blog post may be more for entertainment. I disagree, however--I rely on multiple blogs to help with my every day medical education. I know much more about recent Medicare legislation, new medical studies, and interactions between drug companies and medicine because of reading blogs than I do from my standard education. I receive 3-4 journals a week at my house, and I quickly get overwhelmed trying to read them all. Reading small amounts of blog posts daily, however, is much more feasible, and usually feature links to the actual articles so I can read them for myself.

Publishing case studies is a long-honored tradition in medicine. New diseases and therapies come to attention through case studies--reports of one or a few patients with a given syndrome or receiving a specific treatment. I do not have a problem with the article in Psych Times; in fact I found it enlightening. I simply feel that blog writing should be given the same consideration, given the crossover between internet publication and traditional academic journal.

Sunday, December 14, 2008

That seems wrong, doesn't it? There are plenty of patients who have generalized anxiety disorder who are not psychotic. In fact, I'm not really sure how you'd give someone a diagnosis of schizophrenia and GAD concurrently. To AstraZeneca, however, this difference doesn't matter. They'd like you to give your patients with generalized anxiety disorder an antipsychotic every day, preferably for the rest of their lives.

Confused yet? Don't believe me?

November 2008's American Psychiatry News published an article titled "Study: Quetiapine Monotherapy Works for Generalized Anxiety Disorder" (Vol 1 No 11, p22). The authors discuss data presented on a poster at the meeting of the Anxiety Disorders Association of America, funded, of course, by AstraZeneca, makers of Seroquel XR. The study randomized 234 patients with GAD to receive 50 mg, 150 mg, or 300 mg of extended-release quetiapine versus placebo. The meds were taken for 8 weeks with a 2 week discontinuation taper at the end.

"The most common adverse events were dry mouth, somnolence, sedation, dizziness, headache and fatigue. During the treatment phase, 15.9% of the patients taking quetiapine XR 50 mg per day withdrew as a result of adverse events, as did 18.1%, 24.4% and 6.4% of those receiving quetiapine XR 150 mg per day, quetiapine XR 300 mg per day and placebo, respectively."

So, the patients taking 50 mg of Seroquel XR improved by 2 extra points on a rating scale, but were 2.5 times as likely to withdraw from the study because they felt the side effects were too severe. That's important here. These patients are saying the improvement in their anxiety was NOT as significant as the addition of the side effects of the medication, given how many of them discontinued the medication.

In the US, you only need to show that your medication is better than a placebo to get FDA approval. Let's ignore the fact that there are multiple good treatments for generalized anxiety disorder, from SSRI's to buspirone to long-acting benzodiazepines to non-pharmacologic therapies like CBT. Let's ignore the fact that AZ is trying to win the approval specifically for Seroquel XR, so if you use plain old Seroquel (expensive enough in its own right) for GAD you'll be using it off-label. Naturally, the drug reps will emphasize the long action and smoothness of XR versus regular (never mind that for most indications, Seroquel can be dosed once daily, which is usually the benefit to using a long-acting form). According to Wikipedia, the Seroquel patent will expire in 2011 in the US, but the XR patent goes until 2017. XR = $$$$$.

*I played a little loose here. The doses of Seroquel XR used in the study were not actually antipsychotic doses (except the 300 mg dose, which was no better than placebo). At 50 and 150 mg doses, you're getting a whole lot of anti-H1, or antihistaminic, effect; some antimuscarinic effect (hence the dry mouth), and probably some anti-serotonergic effect (which likely gives it mood stabilizing properties). No anti-dopaminergic effect. So, using 50 mg Seroquel XR is more akin to using an SSRI + Benadryl than to using Haldol. It's just a LOT more expensive than SSRI + Benadryl. Naturally, we don't have any data to show how Seroquel XR compares to any of our other therapies for GAD, but AZ doesn't have to ascertain this, so they won't. And economically, they shouldn't, if they want to sell shitloads of Seroquel XR.

This is the kind of thing that drives me crazy about psychiatry, medicine, drug companies, etc. There's nothing inherently bad about Seroquel XR; there's nothing wrong with AstraZeneca trying to make money; there's nothing wrong with the article as published, per se. It's just the whole thing put together feels like a huge scam. "Statistically significant" doesn't necessarily mean anything, especially when the clinical effect is small and the side effects were so bothersome that within 2 months 15.9% and 18.1% of patients (at the effective doses) had quit taking the medicine. For those of you who may be in medical school, suffering through evidence-based medicine classes, wondering why in the world do you need to know this crap, THIS IS WHY. So you can be an informed prescriber and consumer of health care dollars and not just take the word of the local drug rep, or even the word of your "Clinical Psychiatrist's News Source".

Wednesday, December 10, 2008

This has been a hot point ever since it was introduced several years ago. Recently, it has come to the attention of several prominent bloggers; see here or here or even here. It seems the recent hullabaloo came after the Institute of Medicine released a report on resident duty hours where they recommend decreasing the length of a shift even further, to 16 hours, with more naps, at an estimated cost of $1.7 billion to hire the additional staff necessary to make up the gaps in coverage. All of the above links give excellent, thorough analysis of the situation, including some of the history of the 80-hour work week idea, so I won't repeat it.

As a med student, I didn't log or keep track of my duty hours in any way. I'm reasonably sure that I worked around 80 hours a week on my medicine rotations, and possibly on surgery, but likely no more. I was gung-ho for the cap rules at that time. Many attendings who talked about it gave crappy reasons for hating the 80 hours, like "I went through it, so should you." I never heard a rational, reasoned argument against it in med school. I felt like, 80 hours sucks and is a lot, but it could be worse, so why not?

Then I became an intern.

One of my rotations in the past few months had a night float system for covering patients overnight when your team wasn't on call. It was a terrible system. Essentially, multiple teams would print out 1-page spreadsheets of their patients and then come "check out" to me, usually while I was trying to write notes or admit patients or otherwise do my work. These check out sheets had only the barest of information on them: name, MRN, age, 1-liner about their problem, code status, and anything specifically for me to check up on overnight. Stat electrolytes, stat PTT's for heparin drips, stat H&H for GI bleeders--they'd give me a time, and I'd write down when I should check it. All in all, I estimate that I'd hold about 80 patients' worth of information in my hands by around 6 pm, including my own (the float shift would start after a full day call of admissions, so I'd still be working up my own patients and writing H&P's while taking checkout and seeing float patients).

Then the pages would start. "Mr. so and so is asking for pain meds." I'd go to the proper sheet, look him up, and voila! Absolutely no reason listed for him to have pain. I'd go into the EMR, look him up, no notes documenting pain but "he says he has bursitis in his shoulder and he really wants Vicodin." On principle, I'd try negotiating ("give him ibuprofen first") but usually ended up just writing for PRN Vicodin to save my sanity, as every time the pager would go off for Mr. Bursitis I'd die a little more inside.

Then "Mrs. X's fingerstick reads 'Hi' and I rechecked it twice". Or "Mr. B is having a-fib and his heartrate is 150 and his blood pressure is 90/60." And so on, and so forth. Every time the pager went off, I'd shuffle through a huge stack of papers, trying to figure out who the F the nurse was asking about (and usually trying to decipher the accent), then I'd look them up and try to decide what the hell to do. I had a back-up resident who helped me with anything serious, but still. Being the main doctor overnight for so many patients, almost none of whom you know, is seriously frightening. The potential for error on my part, as I tried desperately to flick through the comptuter for 30 seconds while the nurse waited impatiently on the phone, was huge.

Much has been made recently of the sleep vs handoffs argument. It is true that handoffs can increase the potential for error. I'm not sure if there are any studies that can truly say that handoffs increase the error MORE than working >80 hours (or longer than >30 in a shift)--if there were, the answer would be easy. I will say that after working my first of these night float shifts, I was much less cavalier about checking stuff out to the float. As float, I barely had time to go to the bathroom or examine my own patients, let alone check labs q 1 hour for other peoples' patients.

Obviously, there are programs that have different (and probably better) ways of handling cross-cover. The Day Float resident is a great idea: someone who shows up during post-call rounds, learns all the patients, then stays into the afternoon to finish orders with the attending when the rest of the team leaves around noon. Having a limit to the number of patients allowed per resident on cross-cover might be okay, so long as you can put extra residents on the float shift. Big hospitals will have to have different solutions than small hospitals, where one resident could feasibly cover all of medicine or surgery overnight.

Given the choice, when I desperately wanted to go home but I needed to see if Mr. Y had pneumonia or my patients needed morning labs or I needed to check the orders to see if everything was done, I chose every time to stay and do it myself. I'm not bragging about myself in this, because most residents do the same thing. When they slap "MD" on your coat and it suddenly grows a few feet in length, there's an enormous sense of responsibility that falls on you. Suddenly, these are YOUR patients. If something gets overlooked and the patient gets sick in the middle of the night, that's not the float's fault, it's yours. Yes, this is partly the over-exaggerated compulsion and perfectionism that is part of most doctors, but it's partly true. In my current system, no cross-cover will ever take as good of care of my patients as I do (and when I'm the cross-cover, I can't possibly do as well as that patient's team). Having someone hassling me about breaking duty hours just added to my stress. (And to be honest, it really hasn't been too much of an issue--I've gone over 30 just a couple of times, and never averaged more than 80, and have always had my 4 days off per month.)

So, what I'm saying is, the 80 hour rule is kind of a pain in the ass. I agree that going back to q3 call with no restrictions on duty hours is medieval at best, and I'd hate to see that happen. I get tired enough working 70-80 hours per week. However, further restricting the hours without helping programs find manageable solutions to handoffs is not going to make it any better. Balancing patient and resident safety is paramount, and should not be mutually exclusive concerns.

I'd like to make one seemingly tangential comment. I've heard a lot of whining that residents aren't going to noon conference because the 30 hour rule prohibits it. Actually, if you arrive at 7 am, 30 hours is up at 1 pm the next day. If you want residents to come to noon conference post-call, just decree that they are not allowed in the building before 7 am the preceding day. And then tell their attendings not to round for 6 hours post-call, so they can get their work done and make it TO the conference. Ideally, there would be food at this conference, which is my favorite motivator. This is not an impossible situation to solve, people.

Tuesday, December 09, 2008

I'll admit to occasionally getting sucked into reality TV. I used to watch America's Next Top Model with some girlfriends religiously. I'm not really a fan, but I understand the appeal of mindless entertainment.

Today, while at the gym, one of the TV's was tuned to "A Real Chance of Love", a new reality dating show on VH1. Apparently, these two charming brothers who weren't classy enough for New York were chosen for this show. Their names? "Real" and "Chance", hence the title of the show. (I must say, these were two of the most ghetto-ed out guys on TV). The episode I saw involved 7 of the women (who are largely split into "Real's girls" and "Chance's girls", but there seems to be some overlap) going to a club with the guys, only the guys get into a fight with a dude who has the nerve to hit on one of the (scantily-clad) ladies. The guys are "Pissed!" at this dude, so they talk smack, dude talks smack, dude pushes, brothers take him down. One of them hits dude on the head with a glass bottle. Girls are pushed out the door into their stretch limo by the producers. In the car on the ride home, they hold hands and pray to Jesus for their "boys".

(It gets better)

Upon arrival at their house, the police are waiting. They individually question the girls, on camera of course, as to what they saw. Who hit the dude with the glass bottle? they ask repeatedly. They threaten to make the girls accessories to murder if the guy dies. Some girls cry, some say "so and so did it" and then change their story, one girl flat out says "guy x did it". One girl says "I'm not talking to you" and walks out, and one girl says "I didn't see nuthin', they pushed us out the door." The guy who did the hitting is locked up in cuffs and dragged out.

Surprise! His brother pops up and says it was all a joke, a challenge! The cops come back in and laugh, and dude walks in--he's fine. The brothers wanted a "Ride or Die" kind of girl (which is the title of the episode), the kind of girl who is loyal to the end and will never give up her man. The challenge winners? The one who just didn't say anything and the one who lied and said she didn't see nothing. The other girls were pissed. "I never talked to no cops before! I got no experience with police interrogation! It's not fair!" says one. The girl who told the truth to the cops is angry that they played with her emotions like that, and ends up getting booted off the show at the end of the episode.

My brain almost imploded on itself.

Not a single one of them mentioned anything about the truth or seemed to give a crap that (for all they knew) a guy was dying in the hospital. It's all well and good that the one chick simply refused to talk to the cops--that's her constitutional right. Any one of these girls could have said "I want a lawyer" and I'd have cheered them on. But for all the rest to straight up lie--if they'd been in a real police situation, that would have gotten them in far deeper trouble. After the fact, they were pissed because they'd never had the chance to lie to cops before, it was hard! The one girl who just told the truth was booted out of the house for not being loyal enough. And I just kept thinking, while watching them pray for their boys, that Jesus would want nothing to do with this situation. These ghetto guys, sitting around with their skanky women, got so mad that a guy dared to flirt with one of their ladies (and who would assume that 7 women all belong to 2 men?) that a fight ensued. Yes, it was all staged, but these girls believed it was all real, and they didn't find it weird!

Truly, the next great health campaign, in the spirit of "Just Say No to Drugs" from Nancy Reagan, needs to be "Get Rid of Terrible 'Reality' TV". Either that, or I'm going to have to put a condom over the television to protect my eyeballs from that kind of syphilitic programming.

Tuesday, December 02, 2008

This advice goes out to all of you who may be interviewing for residency soon. I cannot stress enough, DO NOT BE WEIRD. Do not be weird at any point of the interview process, including the pre-interview dinner/social. At my program, I'm part of the recruitment committee, which means I go to a few of the pre-interview dinners and conduct informal lunch interviews from time to time. I didn't realize last year when I was interviewing that these dinners and lunches are all scrutinized. Let's put it this way: if you think they may be evaluating you, they probably are. And if they're not, you should behave as if they are anyway.

My evaluations of candidates are certainly not the thing that makes or breaks them getting into our program. Rather, groups of evals are piled together to give an overall picture of a candidate. If one resident has an off eval but everyone else loves them, the off eval gets discarded. However, if several residents give off evals, this sends more of a message that this person may be a problem.

Cases in point:

1) Dinner started at 6. Applicant walks in at 6:40 (without calling to say they'd be late), surveys the group, asks "where's the pitcher of beer?", and proceeds to order one from the waiter without asking if anyone else is drinking or wants beer. Don't be an alcoholic at the dinner.

2) At a dinner just prior to the election, an applicant walked in wearing a prominently displayed political button. You simply cannot assume that everyone will agree with you at your interview dinner, and is it worth not getting into a program because someone got offended at your button? (This is a trivial point, for sure, but to me this implies that this person will be so passionate about their politics that they may be difficult to speak to without lengthy political harangues--not that I know anybody like that...)

3) Don't make fun of the male resident's choice of beverage by saying "That's so fruity". Do you know if they're gay? For that matter, do you know them at all? How can you possibly assume that person will not be offended by such a comment (unless you know them well)? (I wish I was making this up)

4) Dinner started at 5, applicant walked in at 5:45, looked at all of us eating, and asked "Oh, did you all get here early?" Awww-kward!

5) Don't spend the whole night talking about how amazing some other program is and how every other program in the country needs to adhere to the same standards as this other program and why doesn't your program do x like that program does?

6) Don't wear a denim jacket covered in fringe. Nuff said.

Actually, these comments were all made about 2 interviewees in some order. Any one of these things would have been okay by themselves--put together, they made most of us uncomfortable at the dinner, and several of us emailed the directors to say so.

Other advice for your interview dinner or interview day:

1) Again, DO NOT BE THE ALCOHOLIC. If people are having drinks, fine. If no one else is drinking and you want one drink, fine. If no one else is drinking and you order a pitcher, that's weird. This is psychiatry, we treat addiction all day--why advertise yours at the dinner? (although, maybe I should thank them for doing so)

2) For your interview, you must have a nice suit. Colored suits or pinstripes are perfectly acceptable within reason--no white, purple, or pink suits, please. The goal of your interview suit is to look nice and blend in, basically. People don't often remember the amazing Chanel suit, but they do remember the girl wearing black stretch pants with a turtleneck, because she sticks out (not even kidding, except that was med school interviews).

3) Tattoos and piercings: depends on the program and the specialty. My program has people who have both, including myself, but I didn't flaunt my tattoo during the interview (it's on my backside, so that would have been difficult). Some interviewers will take offense at dudes with earrings, dudes with long hair, people with pink hair, anyone with nasal piercings, etc. I know some people feel that their raging individualism makes it all worthwhile, and they'd rather die than go to a program where their neck tattoo isn't accepted, but again, I feel that the point of the interview day is to make your appearance NOT STICK OUT. They might remember you if you're amazingly hot, but they'll definitely remember large stretched ear piercings, etc. Why take a chance? Cover it up!

Fortunately, the majority of candidates I've interviewed or met at dinner were very nice, and I don't hesitate to pass on that I think so. I'm sure I'll have more to report back after interview season is over, so stay tuned!

Thursday, November 27, 2008

We were talking about code status last night, and how it's really terrible that families get forced to make decisions about life or death. I know it's not a cheerful Thanksgiving Day topic, but as usual it tied in to some patients I treated whose families made them "full code" at 90 years old with advanced dementia, diabetes, heart disease, emphysema, strokes, etc (and usually all of the above). It's too late at that point to ask the patient what they want, so we rely on the families to help us. Unfortunately, I think it's human nature for families to balk at this, or to balk at withdrawal of care discussions when the loved one got intubated and is now in a persistent vegetative state on the ventilator. Who wants to be the one who "killed" Grandma? Isn't that how we would feel, if we make the decision to pull the tube, or the patient is crashing and doctors ask "should we intubate, or let her go?" (Not in those words, but you get my drift).

How much simpler if patients told us in advance what they wanted?

Having already had this discussion last night, I was surprised to see the One Slide blog rally going on today, and decided to jump on the bandwagon. Go check out their website to learn more, and then have the discussion with someone. They call it "Engage With Grace". It's easy. We fear death so much in America that we forget that life has a 100% mortality rate. Death is not always the worst thing that could happen to us. Tell someone what you want done to you when you can no longer decide for yourself. And then listen to your family when they tell you the same thing. Then, it's no longer your decision--it's the patient's decision, which is where it belongs.

Tuesday, November 18, 2008

Thursday, November 13, 2008

Post Night-Float Call-Induced Delirium (may also be known as Post-Call Delirium)

Symptom Criteria:

a) disturbance of consciousness--manifested by inability to pay attention during rounds, falling asleep during rounds or morning report (or while driving home), inability to speak coherently while presenting patients, etc

b) a change in cognition or the development of a perceptual disturbance--manifested by forgetting what one was saying in mid-sentence, forgetting to print a copy of one's H&P prior to presenting the patient, not being able to answer simple questions on rounds, delusions of nursing staff conspiring to page q3 minutes while patient is trying to sleep, etc.

c) the disturbance occurs solely on the morning and afternoon after a night of call or night float

d) the disturbance is not better accounted for by an underlying dementia, substance (must rule out caffeine intoxication), or general medical condition

Etiology: directly related to the quantity, frequency, and quality of pages received overnight during the call or float shift. Direct correlation between repeat pages for Vicodin in a patient with "knee injury" that is not addressed in primary team's notes (and primary team d/c'ed the Vicodin) or pages to give detailed prognostic information to a family member after normal hours when the primary team had several discussions with them during the day, and the severity of the patient's symptoms.

Prognosis: good. Encourage night/day orientation (give patient bright light in the day and full darkness at night), re-orient them frequently ("You're presenting Ms. X, remember?"), withhold further caffeination, encourage proper nutrition (donuts and leftover pizza don't count), TURN OFF THEIR PAGER AND ALERT OTHER SERVICES THAT THE PERSON IS NO LONGER RESPONSIBLE FOR EVERY MEDICAL PATIENT IN THE HOSPITAL AS OF 0700, ensure that the patient makes it home safely and does not fall asleep while driving, and encourage a refreshing post-call nap.

Addendum: This cracked me up: "It may also be associated with post-call dysphoric disorder, as manifested by irritability and the irrational belief that everything "sucks"."--thanks Midwife With a Knife!

Monday, November 03, 2008

At various points in medical training, you go through brief intense phases where you must acquire new knowledge at a tremendous rate. (I would say this is a "steep learning curve", but according to Wikipedia, this is the wrong way to use this phrase. Who knew?) Once you start clinical rotations, usually in the third year, you are constantly getting knocked off balance. In medical school, I rotated in 4 different hospitals and at least 6 different clinics in two years. At the start of every rotation, there's a new place to learn, new medical language (especially on OB), new medical record systems, etc. Every time you start to get into a routine and get comfortable, it's time to move on.

It's just like this as an intern, only even more dramatic, if possible. The first few days of a new rotation are, in technical terminology, guaranteed to suck hardcore.

It's November, and I'm on my 5th rotation, my 3rd hospital, my 3rd electronic medical records system, and my 4th new service. Even though I've been to this hospital before, every unit and service are different, so I'm relearning all the procedures of daily medical business, like how to arrange for discharges (on my last service, we met weekly; on this one, we meet daily). The call schedule is different and complex, with day call, night call, short call, and a ghost team that I don't fully understand. Every day, I have to try to attend morning report at 8 and noon conference (the benefit here is free food), but some days it's grand rounds here and some days it's grand rounds there and others it's simple noon conference in room X.

I have a small book of various call schedules, specialty schedules, and enough phone numbers to make a yellow pages. It takes me 3-4 minutes to find the phone numbers I need every time I want to make a call.

I had two med students over the weekend helping me out (and they're quite good), and today we acquired two more, plus a co-intern, and a new upper level, and an attending I'd never met before, so I'm thanking JCAHO or whomever that we all wear nametags or I wouldn't know who anyone is.

On Saturday, I inherited 7 patients, which is more than I've managed at one time as an intern. One had been in the hospital for 5 months when I picked her up.

Add to this the complexity of actually learning the medicine I'm supposed to learn this month. When my upper level says "replace his K" I usually go "okay, how?" Potassium comes in multiple oral and IV forms and can be administered slow or fast or even hanging upside down for all I know. As a med student, you generally don't learn medication dosing, because you're too busy learning the medicines themselves. Now, I'm trying to learn the dosing, in addition to remembering which calcium channel blocker is a dihydropyridine and which tricyclic antidepressants have the least anticholinergic side effects. Thank god for the PDA (or in my case, the smartphone) that contains the free Epocrates and gives me a starting point to say "should we start metoprolol 50 BID?" (Of course, the answer to most of my dosage offerings is "no, let's start x dose instead", which often seems to be more a matter of personal preference than anything. Or maybe I'm just always wrong.)

I spend half my day (it seems) just looking up the acronyms and abbreviations, because in every place they're different. One service used "HLD" for hyperlipidemia, this one uses "HLP". "MDS" is myelodysplastic syndrome, "SSS" is sick sinus syndrome, "AVR" is aortic valve replacement, and "FUBAR" is how I have felt these past three days. Thank god for Google.

I fully expect that by next week, I'll have my groove down. I'll fly through my notes and know how to replace basic electrolytes and remember the intricacies of acid/base metabolism and how to read an EKG. I'll know the names of the nurses (or at least the main ones) and the social workers (and of course, my team). I'll know my patients backwards and forwards and have their discharge plans in mind shortly after admission (always subject to change, of course). Seven patients will seem like nothing at all (and I'm sure I'll have more soon, as we admit q4).

Those first few days always suck, though. Welcome to internal medicine!

Monday, October 27, 2008

I haven't yet studied the theories of the etiology of somatization, but I'd like to put forth a few ideas of my own.

The term "somatic" simply means "of the body", so what I'm referring to are bodily symptoms that cannot be explained easily by bodily findings. "Psychosomatic" may be more accurate, as nearly all physical symptoms are actually "somatic"--only people with phantom limbs feel pain outside their bodies, for example. Somatoform disorders are those where mental disorders present largely as physical complaints. There are complex syndromes like somatization disorder that require multiple different types of complaints from pain to GI to neurologic, etc; conversion disorder, where neurologic findings don't make anatomical sense and don't have an organic basis that can be found; pain disorder, body dysmorphic disorder, hypochondriasis, and others.

There are people who don't necessarily fit these categories, but just have a lot of "somatic" complaints, especially pain. Patients with lipomas who complain of extreme pain, patients who have a ton of "allergies" to medications (like palpitations from a vaginal metronidazole preparation?), etc. I've seen a few men with small hydroceles/spermatoceles (no redness, no swelling, no pain on palpation during my exam) who complain of severe, disabling pain; a few women with small ovarian cysts, non-ruptured, who complain of the same. Some of these patients have a small physical finding that seems to bother them so much that they have constant pain and disability from a condition which should only rarely be painful. Is it anxiety? I'm not sure.

Sometimes, of course, there's an inciting trauma or injury that induces chronic pain or symptoms. Acute back pain has a pretty high chance of leading to chronic back pain. I've seen multiple patients who had car accidents and end up with years of pain afterward. Why is it that children break their bones all the time and only rarely end up in chronic pain, yet so many adults end up with unending pain?

Is it that having pain for too long leads to chronic pain? The body can become conditioned to things, so perhaps pain leads to more pain. Of course, pain is a poor example, though one of the most common, because pain is neurologically mediated. Other conditions, which have a lot of crossover between "physical" and "mental", such as irritable bowel syndrome, have some reliable clinical findings and may have more organic basis than was originally thought.

Is it possible that some of these syndromes have an organic basis? After all, if thoughts ultimately come from release of neurotransmitters and electrical pulses, then technically everything we think, feel, and do is "organic". The line is pretty hard to see.

Many of these conditions, even if they are ultimately found to have a neurologic basis, are still intimately tied in with psychiatric disorders. Multiple sclerosis patients often have comorbid depression, for example, and experience symptoms when under stress. In my very limited experience, many of these "hypersomatic" individuals, the ones who react badly to most medicine, the ones with chronic vague symptoms and normal physical exams (not the ones looking for drugs, either), often seem unhappy. My life sucks because of this knee pain. I can't work because my back pops because I was tackled at the age of 10. My marriage ended, but now I have 10/10 pain from a bruised finger. Some patients end up on disability, but still aren't happy and have symptoms. One man had vague symptoms every time he walked into his apartment--and then would come to the emergency room for a nosebleed which had stopped, nausea that didn't start until after leaving the apartment (but must be related), etc. He never found it strange that no one else got sick while inside his apartment, even when spending significant time there; he only knew that he felt extremely ill, with widely varying complaints, and his symptoms were not going to stop until he got a new apartment.

Is there a link between unhappiness and somatic complaints? Intuitively, I would say yes. I haven't looked up any data tonight, but I wonder how many happy people suffer from chronic pain or chronic complaints. Or if they have chronic pain, they attempt to go about their life, not spend all their days in the emergency room.

Of course, illness can make you unhappy, which can make your illness worse, and make you more unhappy. Perhaps the answer is just to sing "Don't Worry, Be Happy" all the time. Except that song really doesn't make ME very happy, but oh well.

Sunday, October 26, 2008

My husband has watched all the political debates, while I only watched a few (and honestly, got bored within 20 minutes and kind of zoned out). It's surprising, though, that neither of us had heard about this until now.

I'm going to try to be politically correct, but I will express my opinion here: I am pro-choice. I do not like abortion. I do not like that there are some women who have multiple abortions because they cannot be bothered with birth control.

But neither do I like that so many women are so incredibly ignorant of their options or about sex in general. And I really don't like the idea of criminalizing a procedure which can actually be performed to save a woman's life.

John McCain has an opinion on this, apparently. He said in the third presidential debate that "health for the mother" has been stretched to mean "almost anything" by the pro-abortion movement in this country.

Is this true?

I not only believe that there are situations when abortion is clinically advised, but I have witnessed situations where a surgical abortion had to be performed for the health of the mother. I am making no statement about how often this occurs, and it is totally possible that this gets exaggerated by some in the pro-choice crowd. McCain may not be totally wrong there.

However, to just write off "health of the mother" as simply a "pro-abortion" tactic is to deny that this procedure exists for a reason.

I watched a woman have to undergo a surgical abortion because she had anhydramnios and a fever at 19 weeks gestation. It was a baby she and her husband really wanted, and she was devastated. To protect her health, wait, to protect her life, she needed the procedure. She had chorioamnionitis and the pregnancy was no longer viable without amniotic fluid. At 16 weeks, there was no way to try to save the fetus (which was not yet deceased), and she could not wait 2 months to viability. A horrible situation with a horrible solution, unfortunately.

Of course, being truly "pro-choice" means that had she chosen to refuse the procedure, we would have had to respect her wishes, even if it meant potential death from sepsis and hemorrhage. Some women would make this choice, and though I don't agree with it I understand why they would make it.

Am I exaggerating this case? No. I didn't make it up for the sake of making a point. Is this a rare case? I certainly hope so--I only saw this one. There are other scenarios where the mother's health would be placed in jeopardy by becoming pregnant, of course; renal failure is one, heart failure another, diabetes, etc. These cases all must be judged on a one-by-one basis between the woman and her doctor (and her partner, ideally). To make a sweeping statement that "all of these cases require abortion" is (to me) as ridiculous as saying "none of these cases could ever require abortion."

Of course, the best way to prevent abortion is to prevent unwanted pregnancy, or to prevent pregnancy in a woman who is at such high risk from becoming pregnant. Still, even wanted, planned pregnancies can have a terrible outcome. To mandate across the board that "health of the mother" doesn't matter (as by leaving it out of the partial-birth abortion ban) is to mandate at a legal level the choice some women are forced to make. Even if this is an extremely rare condition (and I think it is, although I do not have stats on this), it seems to me grossly unfair to have a law which makes the decision that a woman whose health is jeopardized and whose life may be in danger must not terminate her pregnancy.

And if Senator McCain thinks so little of the "health of the mother" then I think I know what side he will ultimately choose to vote for.

Saturday, October 25, 2008

I have rejected a few comments recently because they seemed like they were drug ads, or linked directly to drug company websites. Sorry if I rejected a legitimate comment, but I don't want ads (of any sort, drug or not) on this site, including in the comments.

Tuesday, October 21, 2008

So, yes, it definitely sucks to wait 19 hours before seeing a doctor. Yes, broken legs hurt. Unfortunately, unless there is cardiovascular compromise, they're not an emergency to the same degree as that of a heart attack, stroke, major trauma, etc. Perhaps $136 is a bit steep to charge the patient, but then again, that helps cover the electronic kiosk where she checked in (equipment, software, and maintenance), the salary of the nurse who evaluated her, the chart that was generated for her (not sure if it was paper or EMR), and the upkeep of the lobby and clinic rooms. I don't know whether $136 is high, low, or appropriate.

Unfortunately, what do you expect in an emergency room that saw over 143,000 patients in 2005? (http://www.parklandhospital.com/medical_services/er.html) And this patient, by declaring her intention not to pay, is just adding to the strain on large public hospitals like Parkland. Did she plan to pay for her xrays and cast?

Waiting 19 hours sucks. Not knowing how long you'll be waiting sucks, but is par for the course in the ER. If you say "20 minutes" or "2 hours" and then a massive MI comes in or a patient codes and takes up all the staff, then the waiting patient gets mad anyway. Lose-lose situation.

Sunday, October 19, 2008

I think it's interesting that, while it seems that many patients do not trust doctors, many seem to have absolute faith in what we prescribe. I could do the world's greatest ankle exam, according to the Ottawa Ankle Rules, and determine that it's a mild sprain and just needs an Ace wrap, but until we've given that therapeutic x-ray, many patients don't feel better. The Ottawa Rules are actually to determine who needs an x-ray, and they are very good at ruling out fracture. Yet, most people I've seen (observer bias) would much rather believe the x-ray than me. Then again, that could be wise, since I'm just the intern, but still.

I had a depressed, anxious patient who'd suffered a trauma in the past ask me about "the new medicine that will cure everything, you know, the one on TV. Why did my therapist tell me it would take years?" That one stopped me in my tracks. I'm not sure whether this is the fault of DTC advertising, poor education, denial, or all of the above, but that's an awful lot of faith in a medicine advertised by the people who make money off it.

I had a patient who requested an antibiotic by name for a sore throat. Said throat wasn't even red. Patient was a bit hoarse, and had post-nasal drip, so I made a diagnosis of allergies with post-nasal drip throat irritation and prescribed allergy medicine and over the counter throat spray or lozenges. "But why can't I take antibiotics?" "Because your throat isn't infected." "But it HURTS!" "Antibiotics aren't pain medicine. Use the spray at the store."

There seems to be something magic about that prescription, written on the pad. Writing ibuprofen 800 mg tabs is somehow so much more official than saying "take four Advil or Motrin from the store". Perhaps the reason the antibiotics relieve the pain more is simply because they're written on the prescription pad. After all, the expensive placebo is more effective than the cheap one.

Also, we want pills instead of other forms of medicine. Intranasal steroids sprays are front-line for chronic allergies, but don't seem (observer bias) to be very popular. I personally don't use mine as often as I should. Of course, nasal irrigation with saline is also extremely effective, but very few people do it (of those who even know about it). It's just not very sexy to run salt water through your nose (I did it tonight--I recommend pulling your hair back first), and much less messy to take a pill.

In some ways, I think we over-rely on medicine to cure what ails us. How many patients really try to get their cholesterol down with diet or their blood pressure down by cutting out salt? I think we need to re-think "preventative medicine". True prevention isn't about catching disease early by screening, it's about actually preventing disease. We're so focused on the pills that we forget that the best prevention means not to take any. Preventative medicine should actually be about encouraging exercise and healthy diet, but those aren't very sexy on a prescription pad. They're vital to preventing disease, but how much of our national healthcare budget is spent on exercise? We're doing better at smoking cessation, but of course, there are pills for that.

Saturday, October 18, 2008

Last month, I worked in a walk-in clinic off the emergency room/department (whatever). A "fast track" if you will, this is the clinic where the not-so-emergent patients get seen. If the chief complaint is "medication refill" or "back pain" or "tooth ache" or "suture removal", they get sent to this clinic. As always, this clinic is a victim of its own success: they take the pressure off the emergency room/department, which allows more patients to be seen, therefore more patients come to the emergency room/department for non-urgent complaints because this clinic exists. Lather, rinse, repeat.

I read several emergency room/department blogs, including WhiteCoat Rants, Ten Out of Ten, and Crass-Pollination, and while I hoped that they were all exaggerating, I had a suspicion they weren't. They're not. I occasionally saw people who really needed help, but more frequently (it seemed) I saw people whose whole existence seems to be about gaming the system for every free thing they can.

One person came in with a list of requests. Not complaints, but requests. He/she wanted pain medicine, refills of all other meds, a cane, free clothes, free food, dentures, and several other things which I can't even remember because the list was so long. I said no, okay, fine, no, no, referral. Since when is the emergency room/department a soup kitchen or the Salvation Army? And I wholeheartedly agree with today's post by Nurse K about the homeless "patient" with the bogus complaint. This same patient with the laundry list was homeless, but was currently NOT sleeping on the street, but instead staying with family. He/she also told me how many beers they drank in a day (the answer was a number >1). So, you have enough money to support your beer habit, but you get angry with me when I won't give you free clothes and insist that you go to a dental clinic to get dentures? Ugh.

Sometimes, it's a family affair. A brother and sister combo came in the other day, one asking for pain medication and a new cane as it had been "destroyed", the other asking for pain medication and a glucometer as it had been "destroyed". It was probably a little passive aggressive of me to document carefully in the chart that this was the patient's third cane in a year. Is there a black market for canes and glucometers?

I'll be totally honest. When I pick up a chart that says "tooth ache" or "back pain", I get put on my guard. I walk in, and make a split-second judgment. If the patient's face is swollen, or they're sitting all tense and not moving, I kind of relax. If they're all relaxed, and smiling as they tell me "doc, I'm doing TERRIBLE", and they have "10/10" pain from a skin rash, I get a little suspicious. One patient was sobbing hysterically when I came in, to the point I could hardly examine them because they wouldn't stop. "OH JESUS DOCTOR I'M HURTIN' DOC PLEASE HELP ME OH DOCTOR HELP ME!" I asked them to calm down, please calm down, TOLD them to calm down, but to no avail. I actually wrote on my physical exam "could not auscultate heart or lungs due to patient's crying". I looked in their mouth, and saw some brown teeth, but nothing red or swollen or infected, so I said "I'll give you the phone number for the dental clinic." "OH JESUS DOCTOR DON'T LET ME LEAVE WITHOUT PULLING MY TEETH OH DOCTOR THANK YOU DOCTOR I'M PRAYING FOR YOU DOCTOR!" This was also, coincidentally, a patient who had been seen previously, given the phone number they needed but failed to call, and somehow needed to call an ambulance to come to the emergency room for this pain.

WTF? So you can call an AMBULANCE for your tooth pain, just to sit in the ER/ED and complain to the nurse that we're wasting your Medicaid by sending you to a different clinic? Oh, the irony. I'm wasting your Medicaid, you're wasting my tax dollars with your ambulance call.

To those of you who may not know, here's a public service announcement: if your tooth is rotten, but not infected, no matter how much it hurts it's not a medical emergency. The emergency room doctors will NOT pull your tooth for free. Spread the word.

I'm being totally honest here because I'm not proud of this response in myself. Why do I feel like every chronic pain patient is scamming me? Why do I care? Seriously, what is it to me if these patients want pain medication? Why does it irritate me?

I could say it's that these patients are difficult, but really, only a few of these patients are actually nasty to me. Sure, it's hard to tell a patient "no" when they ask for Vicodin (by name and dose, and 'nothing else works'), but most of them accept my reasons and whatever I feel like I can give them (usually ibuprofen, sometimes tramadol). It's the few who get nasty who stick in my mind, though, and put my hackles up.

There's also the occasional patient who seems to "dupe" you into feeling sorry for them, or giving them pain medicine because their pain seems genuine, only to find out they were faking, or they start cursing you for taking too long reading their xray, or do something that makes you feel like a huge fool for believing them. This happens to me from time to time, because I really try to believe my patients. I keep trying to fight the cynicism, but it's hard.

A lot of it is in the environment. The attendings I worked with last month would say "Oh my god, another tooth pain? What a waste of time!" It's easy to spread irritation like that. In fact, it seems sometimes that it's easier to spread a bad mood than a good one...

Although not always. One patient had us all laughing hysterically with him (not at him). The attending came out and told me I HAD to go see this 80-year old guy's hand. I walked in, and his thumbnail was hanging off, dangling by a tiny piece of skin; he was totally nonchalant. "WHOA! I've never seen anything like that!" I said. "You've never seen anything like ME!" he said back. He also told us his only allergy was to "women" and that he was "a real tough guy." He was right. We all told his story for days to come, repeating it and laughing, tickled by this patient's attitude. So sometimes the good stories get passed around, too.

I just wish there were more of them, and less frustration. But still, why so much frustration? I haven't found the answer yet. I can totally understand some of the attitudes in the ER/ED blogs, though. There are some NASTY people out there.

Monday, October 13, 2008

I'm working on a post about the health care policies of both candidates, and a thought occurred to me. It all started while watching the second presidential debate the other night. I realized that both men were focused on access to health insurance, but neither fully realized that health insurance is not health care. Obama came near this point when referring to his mother fighting her health insurance company for a "pre-existing condition" in acknowledging that just having health insurance is only part of the battle, but did not encourage access to doctors, just to health insurance.

My thought was, why do we have health insurance?

I own a dog and a cat. I take them to a veterinary chain, where for $25-$50 per month per animal I pay for 2 full checkups per year, including blood work; annual dental work (and biannual for the kitty); required vaccines; and I get a free office visit + 10% discount on any further treatment they need. I can pay for a cheaper plan and get a little less, or a more expensive plan for a little more. I upgraded the dog a few years ago when he started needing dental cleanings, because it was cheaper and easier to pay for it over the course of a year than all up front.

Why don't we have similar plans? Why do we need large insurance companies to be our middle man? It seems like (to be overgeneralized) the insurance companies (and the drug companies, but that's a different story) are the only ones making lots of money here; they squeeze hospitals dry, they squeeze doctors dry, and they cut out coverage for patients with "pre-existing conditions" or for taking Drug X instead of Drug Y to dictate healthcare for their patients. Until insurance companies are run and staffed by doctors and other healthcare professionals, WHY do we let them dictate our care? Why do we have to argue on the phone with a glorified secretary* (who probably makes more $$ than this intern) about why we, the MD, ordered the MRI?

So why do we need health insurance? Or rather, why do we think health insurance has to pay for everything? Why don't we remember that "insurance" is something for a rainy day which we hope not to have to use, but we have it around just like the fire extinguisher under the sink? Since when have we become too cheap to take responsibility for our own bodies and our own health?

I realize that health care is expensive, and even visits to doctor's offices can be out of reach for some patients, but consider how much cheaper the system could be if we largely cut out the insurance companies. Doctors' office staffs could be smaller because they wouldn't spend all day on hold with Blue Cross Aetna UHC arguing over a $10 copay and begging them to cover a visit.

If we got rid of "managed care" entirely, and went to a system of high deductible "rainy day" policies for those people who were healthy, and got rid of the middle men so patients could negotiate care with their own doctor, health care prices would fall as competition evened out the playing field. Patients with chronic health problems or who needed more care would have to pay more under such a system (they do now, too), but even they could still negotiate with a doctor and then purchase insurance to help cover costs they couldn't afford.

Insurance companies get their $$ another way, too, by selling malpractice insurance to physicians, which may cost up to $250,000/year for some specialties. Putting caps on malpractice settlements may help, but does not solve the problem. Perhaps a solution other countries have tried may work: make the plaintiff pay for something if they lose. Or make the plaintiff pay a small court fee (a few hundred to a few thousand or so) in advance, to be refunded if they win. Or make the plaintiff's attorneys (another group making $$$ out of the healthcare pot) pay fines if they sue frivolously, or cover the defense's court costs for fighting the battle. Right now, plaintiffs and plaintiff's attorneys have nothing to lose by filing in court, where doctors have everything to lose just by getting named on the lawsuit. Oh, but what about the poor plaintiffs who can't afford to pay the court costs? Where does it say in our Bill of Rights that we are born with the right to sue?**

Obviously, this scenario leaves out a big player in this business: CMS. The rules would have to change dramatically for CMS, too, because they essentially dictate the amount physicians will be reimbursed for services, and then most insurance companies adjust their reimbursement rates based on Medicare's. I'm fresh out of ideas at the moment as to how to fix Medicare, but my main point is this: there are a lot of fingers in the healthcare pot. A lot of non-physicians are controlling healthcare dollars on behalf of patients, doctors, and hospitals, and currently very few players are winning. The ones who are winning are not the health care providers, the hospitals (at least, the non-profit ones), or the patients. So why are we letting all the wrong people benefit from our trillion dollar healthcare budget?

*I have nothing against secretaries. I am totally inept when it comes to those huge phones with the transfers and hold and multiple lines, gah! **Lawsuits can occasionally be necessary or justified, including those against physicians and hospitals. I'm not opposed to all lawsuits, I'm opposed to irresponsible suing.***Written when I was trying to go to sleep but couldn't. Sorry if it rambles or makes no sense.

Tuesday, October 07, 2008

"I think it's better to have ideas. You can change an idea. Changing a belief is trickier." -Dogma

I love that movie. It's so true.

As we prepare for the presidential debate tonight, I've been dusting off my long-standing, ever-evolving "Thoughts on Belief". I started really thinking about this during high school, when I was an evangelical Southern Baptist. I never really liked to proselytize, however. When I pondered why this made me uncomfortable, I eventually realized it was because if I was "witnessing" to someone, I was expecting them to listen to me and potentially change their mind to agree with me and whatever I was saying. However, I acknowledged that I wasn't willing to do the same. In other words, if I was preaching Christianity to a Buddhist, I wasn't necessarily willing to listen with an open mind to what they had to say back to me.

Out of this initial observation, I drew the conclusion that because I believed I was right, it was impossible for me to truly listen to another person's side and consider their (opposing) beliefs as if they were right. Thus, I could debate with them, and talk with them, and have exchange of ideas, but I would still leave convinced that my side was right, because I believed in it strongly. Only if I were able to suspend my own beliefs, or hold them less strongly, would I be able to truly listen to opposing beliefs.

Over the years, I've made many refinements to my initial theory (which, I admit is not original--I'm sure a philosopher probably reached similar conclusions 2000 years ago). Several corollaries emerged.

One: if I hold beliefs strongly, and someone else has starkly opposing beliefs that they hold strongly, and we debate, it is extremely easy to identify the person with their beliefs. You are no longer my friend A who happens to worship at X temple or vote for Y candidate, you are now an Xist or a Yican. If you identify the person with their beliefs, then the argument becomes intensely personal FAST. This is where a lot of internet chatroom nonsense happens, I think. I can't see you on the internet, so if you endorse a political theory I despise, and you think my theory is bunk, then suddenly we're calling each other Nazis and making comments about your mother's marital status when you were conceived.

Two: if I have a strong belief, and you present excellent evidence which directly contradicts my belief, I will make every excuse and rationalization possible against your evidence. It's one thing to argue for my side and present my own evidence, it's another to stand firmly by a belief despite TONS of evidence to the contrary. See the quote at the top. I'm emotionally invested in my belief, so your attack on it feels personal to me. I can't be wrong, because that feels bad, so I'll do everything I can to protect my belief.

Three: I think this is a normal human thought mechanism (forgive me my Freud-level hubris for applying my personal observations to ALL OF MANKIND). If I have opposing thoughts from you, then that implies that there is more than one way to think about that issue. I've made a decision, though, so I need to defend it in order to defend myself. For me to acknowledge that you are right, I have to change my mind, or continue to just be wrong (and who does that? Who says man, those Hindus have the right idea about God and the afterlife, so I'll just continue to be Muslim?) I'll go even farther and say that I think this is where a LOT of wars come about.

Four: I think this goes beyond just random beliefs and applies to things like choosing political candidates. As soon as we pick our candidate, the statements made by the opposing candidate seem completely ludicrous. How could they say that, are they retarded? we yell at the TV during a debate. What we don't usually think is that the opposing team is yelling the same thing at our candidate during that same debate. How many people wear a candidate's pin or sport their bumper sticker, yet will say openly and freely "Their ideas on such and such issue are really not so good" unless they then say "but the other guy's are even worse!"? I usually only hear such talk from people who are lukewarm, not the redhots.

I've never really put these thoughts into written form before, and so I apologize if they are rambling or completely unoriginal--it's just something I've been thinking about for years, including my philosopher days of college.

Now for a public service announcement: Go vote during this presidential election. Whether you vote Republican, Democrat, or third party, I don't care, just do it. I'm not sure if you can still register in some states or not, but if you can go do it.

And try to have a little tolerance for those who vote the other way. After all, whichever candidate wins November 4th, there will be close to half of the country's population who will be very disappointed.

Thursday, October 02, 2008

Forgive me for just posting a link, but Shadowfax at Movin' Meat has written an amazing blog post which essentially summarizes my thoughts on universal healthcare, only MUCH better written and with a LOT more thought put into it than I usually do. Go check it out.

Oh, and I'll spoil the conclusion he makes: healthcare isn't a right, as we define rights, but an entitlement, and one we should probably extend to all citizens. It's okay if you disagree with this, but it's still a damn fine essay.

Sunday, September 28, 2008

We were talking about this phenomenon the other day: on very consult service I've ever been on, they whine and complain about the crappy, bogus consults they get, yet when those very same residents are on other services, they make those same bogus consults. One resident felt ardently that you should not call a consult unless you've done most of the workup yourself, ie, if you're calling a consult for altered mental status, then you should probably have actually checked the mental status. Others felt like they would call consults for things their physical exam was lacking, ie, calling an gyn consult to do a pelvic exam, whereas I KNOW the ob/gyn docs whine about those consults ("oh my god, we're all doctors, you learned how to do a freaking pelvic exam in medical school"). So when is it appropriate to consult?

For starters, it helps to have a specific consult question. Your question may be diagnosis (What the eff does this person have??), workup (What kind of tests do I need to run?), management (What do I give this person?), or a combination of the above. You may need to consult a procedural service, such as surgery for belly pain or GI for a colonoscopy. Prognosis is another type of consult question, when the consulting service knows the diagnosis but isn't sure what it means for that particular patient. For C/L psych, the consult question may be "This patient is a pain in the ass", meaning that you may have to deal with the patient, or you may have to deal with the staff (or both).

Don't be vague; if you don't have a clue what's going on then say so, but the more information you can give about the patient, the better. In other words, if you're calling a consult for belly pain, say "66yo WF with DM, HTN, Afib, now with intermittent diffuse abdominal pain worse after eating", not "she says her tummy hurts." If the diagnosis isn't clear to you, then give more information, and tell the consultant that's why you're calling ("Look dude, I don't have a freaking clue" usually works, as does "I'm only an intern.")

Of course, following consult etiquette is also important. It's usually best to actually speak to the consultant (or resident) on the phone to give them the patient's info, previous workup, and of course, the consult question. Most hospitals will let you order a consult in the EMR or the chart, but it's good manners to actually talk to the doctors whose help you are requesting. Be polite, always; after all, you're asking them to do you a favor (a favor which is part of their job, but still, they've got plenty to do without your consult). One bonus to the phone thing is that you can request the "curbside" consult--in other words, if you just had a quick question ("What dose of enalapril would you use in a dude with HTN, DM, and a creatinine of 2.5?"), then it doesn't entail a full consult note, just a quick phone chat. Also, if you call, and the consultant thinks it's a crap consult, they have a chance to turn it down ("Hey, man, don't you have UpToDate? Why are you calling me with this crap!")

Where it gets crappy for everyone is in the gray area around the above questions. Sometimes, an attending or upper-level resident may ask the intern to call a consult on a patient they're unfamiliar with, so that when you call, you don't have pertinent patient information. Bad situation. Sometimes, your team will have a plan, but will call a consult "just to get Heme/Renal/Neuro 'on board'". This may or may not be appropriate, so just keep in mind that getting so-and-so "on board" requires them to come write notes, perhaps daily, and it may not be an urgent inpatient matter. Psych patient who is psychotic in the hospital? Sure! Psych patient with a remote hx of depression, not on meds, doing fine, in the hospital for something else? Probably not.

Sometimes, you disagree with your upper level or attending about the appropriateness of the consult, but you have to call anyway. This sucks. However, you just have to suck it up and do it. If the consultant says "Okay, I'll come", then great. If they say "Uh, no, that's a crappy consult", then you shouldn't really say "Oh, yeah, I thought so, but my attending wanted it..." I think it's okay to say "My attending requested that I call you," but badmouthing your attending is never a good idea, unless you're home with your non-medical spouse and you're sure no one else is within a 50-mile radius.

Other than the basic rules, just keep in mind when you're on a consult service that no one else in the hospital has the expertise that your team does in your subject. Sure, you think "Well, we all went to med school, they should know such-and-such," but that's not always the case. Also, teams are busy, and may not have or want to take the time to research a topic they're unfamiliar with. So instead of thinking "OMFG, not another consult for Bell's palsy/remote psych hx/benign tachycardia/delirium/benign colonization of urine with a Foley," try to think of it as an opportunity to teach. Or, if you prefer, a time to feel really smart compared to someone else. And just remember, when you're on your next rotation, to kiss up a little when you call your old team for a crappy, bogus consult.

Saturday, September 20, 2008

Inpatient rotation with q4 call = busy TS. Sorry for the lack of posts. It will probably be next week sometime before I can start posting with regularity (sounds like something you take Dulcolax for, doesn't it?) Anyhow, I'll be back soon!

Sunday, September 14, 2008

To those people who chose not to evacuate when placed under mandatory evacuation during Hurricane Ike:

Your decision not to evacuate, despite being warned of storm surge threats and of the threat of the hurricane, has placed hundreds of rescue workers in danger. In addition to having to rescue people who could not leave (those who tried to call 211 and could not obtain help, or those without means or were ill), or those who were in areas without evacuation who experienced flooding or fire, they have to come rescue those of you who said, "well, the last hurricane didn't hit us, so we didn't think this one would hit us, either". I'm sorry your house was flooded, and I'm sorry that you suffered, and fortunately you are still going to get rescued. Unfortunately, though, you are increasing the burden on rescue workers, hospitals, law enforcement, etc, and it's entirely through your own choice. If you have children and didn't evacuate those children, then shame on you for putting them at risk when you were TOLD to leave.

It's akin to a severe diabetic not taking insulin and eating cheeseburgers despite warnings that they could lose their heart, brain, kidneys, and extremities. We will still come fix you, but if you had helped yourself then we'd all be in a much better place.

To everyone in the areas affected by Ike, my thoughts go out to you. I hope everyone is okay.

Monday, September 08, 2008

I've run across some misinformation amongst some of my family members recently, regarding the use of defibrillators. Articles like this one from February indicate that they're not the only ones who may not understand. So what is a defibrillator, and what is it good for?We'll start with the heart. It beats between 60-90 beats per minute (normally) in all of us who are alive to read this. The heart beats because inside the heart the "pacemaker", or sinoatrial node, generates an electric signal that courses through the heart muscle, which causes the muscles to contract, forcing blood up and out.

When the rhythm of the heart beat is normal, we call it "normal sinus rhythm". It looks like this:Sometimes, the electrical system of the heart gets screwed up. It starts to fire in an abnormal fashion, causing the heart beat to become abnormal. We call this an arrhythmia. There are many types of arrhythmias. You can start with slow versus fast patterns. The thing to remember is there are MANY TYPES. Since there are many types of arrhythmias, it makes sense to think that patients have many types of reactions to their arrhythmias. Some patients with a benign arrhythmia may have no symptoms or may have severe symptoms. Some have a potentially lethal pattern and may have severe symptoms or no symptoms.

Now, what do you see on TV? Patient says "I can't breathe!", grasps their chest, and keels over; someone slaps the paddles together, yells "CLEAR!", then you hear BOOM! and the patient sits straight up, fit as a fiddle.

Not exactly.

In real life, the paddles only come out when a) the patient is sick enough and b) the rhythm is shockable. On airplanes and in school gyms, automated external defibrillators may be used instead of the big fancy paddles. Someone goes down, isn't breathing, and they look bad. Bystander grabs the AED, slaps on the pads, and the machine starts to analyze the patient. It has two options: shockable rhythm or non-shockable rhythm. That's it. The machine doesn't know if the patient is breathing, or conscious, or has no blood pressure; the machine simply knows whether it should deliver a strong shock or not.

So when will the machine deliver a strong shock? Two rhythms only: ventricular tachycardia and ventricular fibrillation. Both of these rhythms can be fatal, as the heart beats too fast to pump blood, so the brain dies, and the heart wears out, so it dies.

Unlike on TV, if someone's heart has stopped completely, or is in asystole, they don't get shocked. In that case, the only thing to do is good old-fashioned CPR: manual chest compressions and mouth-to-mouth (or bagging if you're in a hospital).

Thus, if you strap on an AED, it will not always shock the patient. It shouldn't. Pulseless electrical activity, where the heart has some electricity but isn't pumping blood to the body, does not respond well to shock. Asystole does not respond well to shock. The slow arrhythmias, unless they start having ventricular fibrillation, do not respond to this kind of shock (and require a special pacemaker). The correct thing to do, if the machine says "no shock advised", and the patient still isn't breathing, or has no pulse, is to continue CPR.

AED's can and do save lives--it's true. You can't go wrong by strapping one on someone who's down without a pulse and not breathing. But don't forget the CPR.

So, what was my family's misinformation? They thought that the machine always shocked--and therefore always saved. Not true. And unfortunately, if there's not a shockable rhythm, and the patient can't get help within minutes, their prognosis is grim, even with the world's greatest CPR (although with CPR is better than without). A patient who goes down may still have a poor prognosis even if the AED delivers a shock, but now they've got a fighting chance. Since you don't know why the patient is down--they may have had a heart attack, or a stroke, or a pulmonary embolus, or a chemical imbalance in their blood, any of which could trigger an arrhythmia--it's good to strap on the machine and do CPR.

Something random and (I think) fascinating: Hands-Only CPR can be just as effective as the regular kind. So, if you're worried about doing mouth-to-mouth, or don't have your barrier device handy, just work on the chest compressions (100 per minute, so faster than 1 per second, and compress the chest 1.5-2 inches in an adult).

--I'm going to use this for my family and other lay people who have questions about CPR and AED's. Let me know if there's something I should fix.

Saturday, September 06, 2008

Just for fun, while watching Season 4 of The Office tonight, I started thinking about DSM-IV criteria and the main cast of characters (yes, I'm a huge nerd). Obviously, these personalities are exaggerated for the sake of the show, because nowhere else on earth (except a psych ward or prison) would you see this many personality disorders in one room--they'd all kill each other. See what you think:

1) Michael: dependent personality disorder vs narcissistic personality disorder; manifests splitting, self-destructive behavior, pathological need to be liked, feels entitled, has some somatization, fears of being alone, rushes to new relationship when old one ends

2) Dwight: paranoid personality disorder vs schizotypal personality disorder; feels everyone is out to get him, has hidden weapons in the office, turns down a free drink because it may be poisoned, has some magical beliefs (the computer has free will, the websites are talking to each other to take over the world, the short guy is a Hobbit), ideas of reference, eccentric behavior

12) Ryan: narcissistic personality disorder vs substance abuse NOS (I'm not sure what but he was definitely on drugs in that club, looked like Ecstasy) vs pyromania*

That leaves Jim, Pam, Oscar, Darryl, Stanley, and Holly without a current diagnosis. Any thoughts?

Obviously, this is satire, and I just made this all up. This information is not intended to diagnose or treat any condition. I do not think everyone I meet has a personality disorder, I swear. It's just a joke. No, really. Stop looking at me, swan!

Saturday, August 30, 2008

The past week or so, I've been experiencing an internal struggle. It's somewhat akin to a loss of faith, if you will, similar to what I experienced at age 19 when I became an agnostic (from Southern Baptist--trust me, that's a big leap). I've felt lost, confused, somewhat abandoned, and angry. While the acute crisis has mostly passed, I'm still feeling the aftermath and haven't decided yet what to do.

What was bothering me so much?

I have been confronted with evidence that a good portion of what we do in psychiatry is based on a) ineffective medication b) bad evidence on medication, sometimes even manipulated by drug companies c) made up as we go along. It just seemed to happen all at once, however, and kind of rocked me: can I "believe" in psychiatry, and practice in this field, if so much of what we "know" we don't actually know?

Some of you are going "WTF?" and some are going "DUH!" I'll try to list examples of what I'm talking about.

1) I've known for some time that the evidence for certain "mood stabilizers" like Depakote isn't very good. In fact, it sucks. In the study linked above, Depakote was no different from placebo in preventing mood episodes. Yet, we put every freaking bipolar patient on Depakote. It does seem to be effective in acute mania, but not quite so much in maintenance. And the whole term "mood stabilizer"? Doesn't it imply that the mood is "stable", or non-fluctuating? Even in trials with relatively good improvement over placebo, like this one with lamotrigine, show that the mean time to intervention for mood episode while on maintenance was 200 days (versus 93 with placebo). So by 6.7 months, the average patient on lamotrigine was going to have another episode. It may have reduced the risk of relapse, or prolonged the time to relapse, which is good, but I'd hardly call that a "stable mood".

2) A recent meta-analysis shows that overall, SSRI's aren't terribly effective in all but the most severe depression. Yet, we're taught in medicine that roughly 2/3 of patients will respond to the first antidepressant you try. It all comes down to your criteria, I suppose; remission vs response vs decrease in symptoms on a clinical scale, etc. Interestingly, the study above re-analyzed ALL the data submitted to the FDA to get these drugs approved, and came up with this answer. Uh, where was the FDA? Aren't they supposed to do that?

What really bothers me about this one, though, is that some of the efficacy data that was used to get these drugs approved in the first place was deliberately manipulated to make these drugs look more effective. After reading "Side Effects" recently, and looking at the study the book discusses, I'm angry. Wading through that study is tough, but you could still come out and think, well, it showed SOME benefit over placebo, and the side effects weren't too bad. Turns out, what was coded as "emotional lability" was actually likely to be suicidal behavior or self-mutilation. AND, several kids' data disappeared from the analysis. AND, the study was ghost-written. AND, GlaxoSmithKline deliberately had the writer word the study to show that "Paroxetine is generally well tolerated and effective for major depression in adolescents" because they knew it would hurt their bottom line to write that it wasn't! (That's not so shocking, really...)

Whether you believe that SSRI's cause/increase/exacerbate suicidal behavior or not (I've seen convincing arguments both ways), it is highly disturbing that the evidence we've been basing therapy on was so deliberately manipulated. Yet, we use this "evidence" all the time. It came directly from a drug company that expected to make millions to BILLIONS of dollars off this medication.

3) People ask me all the time if I'm going to become a child psychiatrist. After all, I love children, and (if I may say so) I'm pretty good at interacting with them. (Maybe I'm just childish?) However, my answer is usually "No." Why? Because I don't like the way we medicalize childhood problems and then medicate them.

Is ADHD a real disease? Sure, why not? I've met kids who were really impaired by their hyperactivity and impulsivity, across settings, with good, appropriately firm parents. I've also met kids who were totally out of control in the doctor's office while mom chats on her cell phone and then looks at me funny when I tell the kid not to hit their sister with the otoscope.

I have seen the number of kids diagnosed with ADHD go up dramatically in my lifetime, and (concurrently) the number of kids getting put on stimulant medication. What happened to behavioral modification? Or family therapy? I've not once seen those prescribed for a patient with ADHD (though my experience is still very small).

And then there's the whole pediatric bipolar debate. Can a 4-year-old kid really be manic? I don't know. But apparently the FDA does, because they're willing to approve medications for use in pediatric bipolar, when even the DSM-IV doesn't have a criteria for it yet, because no one has agreed on what the criteria should be! And apparently Texas knows what it is, because 12% of 0-5 year olds and 2/3 of the teenagers in foster care are taking "psychotropic medication". Twelve percent of kids under 5, and we don't have any idea what these meds might be doing to their developing systems.

So no, I don't think I can be a child psychiatrist, unless I do only therapy, because a) there's very little evidence in kids, because who wants to do studies in kids? b) the studies we have may be flawed c) but we "have to do something" when little Johnny hits his sister, so here's your Risperdal, hope it doesn't zonk you out too much. Oh, it makes you too sleepy in the day? Well, we can try Concerta during the day! Side effects from the Risperdal? Take a Benadryl! We end up with young kids on 3-4 psychiatric medications, and we don't know what any one of them could do to these kids, let alone a combo of multiple.

4) We act like psych patients who are "non-compliant" are constantly wasting our time. I wonder, how many psychiatrists have ever taken, say, an antipsychotic? I've never taken Zyprexa, but I know people who have, and they were complete zombies (who got fat). We act like we're surprised that patients would prefer craziness to weight gain, or sedation, or extrapyramidal symptoms, or (god forbid) tardive dyskinesia. In reality, I think we're asking patients to make a tough choice. Schizophrenics don't get totally well on medication--there is no cure. So, they can have an improvement in their psychosis and mood with a ton of unpleasant side effects, and be quasi-functional, or they can be psychotic and flat and non-functional. This is a tough choice, and we need to appreciate that.____________________________________________

I guess what's really been bugging me is the huge discrepancy between what we're being taught (in both med school and residency, now) and what is actually out there. We're so "evidence-based"--but so much of our evidence comes from drug-company studies. Or what we "know" is directly in conflict with the "evidence." I don't want to be taught how to dose a medication without knowing the evidence behind it. Is that too high a standard? I don't think so. Would it be any different in medicine or pediatrics? Probably not.

In so many ways, though, I feel like what we do in psych is far behind the rest of medicine. Look at how many options there are for treating hypertension: beta-blockers, calcium-channel blockers, thiazides, loop diuretics, salt restriction, potassium-sparing diuretics... Now look at our options for psychosis: typical or atypical antipsychotics. Possibly group or family therapy; hospitalization for "medical stabilization"; group homes for those whom we can't fix. For bipolar: anti-epileptic drugs, lithium, atypical antipsychotics, maybe SSRI's. When one med doesn't work, we just add more, despite having almost zero studies on combo therapy.

This is not what I wanted. I guess I wanted to feel like I could actually help people. Hopefully, by learning psychotherapy, I still can. I wanted to practice "evidence-based medicine"--how can I, when there's so little good evidence? I guess it's one thing to prescribe Depakote because "it's better than nothing" (although it may not be), because we don't have many better options, but I hate the sales job. Call it a "mood stabilizer" and you believe that it works. Your textbook says "used to prevent recurrence of mood episodes" and you see it as actually preventing episodes, as in all (or most) episodes, not delaying their occurrence by 100 days (like lamotrigine).

I really think basic pharmacology ought to have a segment where they examine (briefly) the best evidence for medications (like second-year med students need more to learn). I think we ought to be exposed to that stuff early. Like, study X showed a number needed to treat of 20 for cholesterol-med Y. Or if second year students can't do that, let's put it into the curriculum for clinical rotations in third year. Or in fourth year when we're lazing around on the beach. Or intern year.

I guess I wish someone had handed me a book that I could reference the actual numbers and studies used to say this drug works on this condition. To the best of my knowledge, no such book exists. Shame on us for not having such a book (and shame on me if there is something but I haven't found it.)

So I'm a little burned out right now. I'm getting plenty of sleep and I just had an easy month, so it's not that. I'm just concerned about my chosen profession and its integrity--scary, huh? And will it be enough for me to just "be with" patients (House of God) in the face of our inability to do much else?

Wednesday, August 20, 2008

...why, just lower your grading standards! Which is exactly what the Dallas Independent School District's board has just mandated that all of its teachers do. Dr. Eliu Hinojosa, the superintendent, backs the new rules, which will mandate that teachers accept late homework, give retests for failing tests, and (my favorite) not allow teachers to accept grades on homework that would drop the student's average.

WTF?

So, your average in a class can only go up? What if your average in the class is a 98? Do these people even know how to calculate an average, which includes points both above and BELOW the mean? I guess it wouldn't matter, since these students have zero incentive now to actually DO their homework, anyway, since the teacher can't penalize them for not doing it. Dr. Hinojosa: "We want to make sure that students are mastering the content [of their classes] and not just failing busy work," he said. Oh, so now all homework is busy work? I highly doubt I'd have learned geometry or calculus without practicing at home, and (though I was highly self-motivated) it helped me slog through all those problems knowing I'd get a good grade. I'm sure I wouldn't have been quite so motivated to finish 30+ calculus problems a night if there had been no penalty for not turning it in.

It gets better. Dr. Hinojosa cites research that shows that ninth-graders who are failing 2 or more classes in the first 6-weeks of ninth grade are "doomed" to become dropouts. This is probably accurate, because if you're already failing in the first 6 weeks then clearly the subject matter is over your head or you aren't trying very hard (or both).

Why do I say the subject matter is over your head? The article I linked above goes on to say that teachers are saying the real problem isn't that ninth grade teachers are grading too hard, it's that these kids can't freaking read!

In 2007, 80 percent of them scored below the 40th percentile in reading on the Iowa Test of Educational Development. Yet the promotion rate out of eighth grade for that class was 98 percent. (Dallas Morning News)

So, the majority of these new freshmen read at a below average level for eighth graders. If you can't read well, you can't possibly pass high school courses. Math classes require reading. Science classes require reading. Hell, even drafting, shop, home ec, health, and agricultural classes are bound to require some reading.

This says a TON about the quality of education in the DISD, I think. If 80% of your ninth graders are below average readers, then the quality of your reading program is likely to be--wait for it--BELOW AVERAGE.

So the DISD's answer to their failing freshmen? Lower the standards further. Never mind that nearly 50% of college freshmen from Texas high schools are requiring remedial courses to catch up to their peers. Never mind that the same panel reported that the standards on the TAKS test are so low already that passing this test doesn't reflect that the students are ready for college. Never mind that business leaders are concerned that many Texas high school graduates aren't prepared for the workforce, either.

Let's ignore all of that for a second, and pretend that the problem is that high school is just too hard. Then yes, the answer is to make it easier! If you made a bad grade, we'll just throw that one away!

The real victims, of course, are the students in DISD. Let's take students who are badly prepared by their school to read at a high-school level, and let's give them extra incentives to be lazy. They're going to be told that it's okay not to turn in assignments, okay to make bad grades because they don't count, and then when they hit the "real world" of college or trying to go to work, they're going to be totally stymied. Some of my college classes had 300+ students--do you think that prof gave a crap if I was having a bad day and didn't feel like turning my assignment in on time? And even people who work at McDonald's or a grocery store have to have basic reading skills.

Random data: DISD paid Dr. Hinojosa $327,600 last year. DISD contains 160,000 students currently, 38,586 of whom were in high school in 2007-2008. If 80% read below an eighth grade level (I'm assuming that no further reading instruction was given, so those students reading below the average eighth grader continued to do so through 12th grade), then 30,869 high school students in DISD have poor reading skills and are set up to do badly in high school and beyond. Over the next four years, as those 30,000 students are released on Texas colleges and business as high school graduates (or dropouts), I think we'll see that Hinojosa's rather large salary is a pittance compared to the cost all Texans will pay later for these poorly educated students.

I don't always agree with him, but this time, LawDog has gotten it. Thanks to his site for running this story first.

About Me

This is the disclaimer for this blog. I live in Nowheresville, USA, and I'm not actually a young female doctor, but an old hairy guy living in a trailer typing on a Commodore about my fantasies of always wanting to be a doctor. Everything on here is patently false and should not ever be construed as truth. I made it all up. Also, I'm not YOUR doctor, so if you got here by Googling "how to treat toenail cancer" you need to go visit YOUR doctor. These are my opinions, not medical advice.